56 4 76 5 ANDREW TISCH
62 5 75 7 274- 38- 3042
57 5 61 6 530:
56 7 66 8 PAYROLL:
68 7 71 8 700
30 11 75 14 LOEWS/ LORILLARD PUBLIC AFFAIRS COMMITTEE CONTRIBUTION IDENTITY CARD
7 18 40 20 COMPLETE EITHER A OR B BELOW:
7 22 87 27 A. I hereby authorize, until further notice, a voluntary contribution by salary deduction to the Loews/ Lorillard Public Affairs Committee (LOPAC) of the following amount per pay period:
53 28 59 30 $2.00
24 29 30 30 $1.00
60 31 67 32 $20.00
53 31 60 33 OTHER
24 32 30 33 $4.00
53 33 72 34 (please specify)
7 35 72 39 B. Enclosed is a check or money order in the amount of $ as a contribution to LOPAC.
7 42 87 54 My contribution is voluntary. I am aware of my right to refuse to contribute without reprisal of any kind.  I am aware of the politicial purpose of LOPAC. I am aware that a copy of the report of LOPAC is filed with the Federal Election Commission and is available for purchase. I am aware that the guidelines above as to the amount of my contribution are only suggestions. I am aware that my contribution counts against my individual contribution limit. I am an American citizen or I have been admitted to permanent U. S. residence.
7 60 57 61 THE FOLLOWING INFORMATION MUST BE FURNISHED:
33 62 59 66 Andrew H. Tisch (Print or type)
7 63 22 64 1. Full Name
33 66 81 70 26 East 63rd Street, New York, N. Y. 10021 (Include state and zip code)
7 67 31 69 2. Residence Address
33 71 77 73 One Park Avenue, New York, N. Y. 10016
7 72 30 73 3. Business Address
33 74 79 78 Chairman/ CEO - Lorillard Tobacco Company (Job title or position)
7 75 23 76 4. Occupation
91 80 93 88 92314414
10 80 33 84 
57 82 71 84 1 November 1991
67 83 73 85 (Date)
20 84 32 85 (Signature)
23 89 71 91 Return this form in the envelope provided.
